“Doc, DO I Have Neuropathy?” Case Vignettes to Neuropathy - 4.pdf · Case Vignettes Susan, 50 DM – 12 yrs B/N/T – 2 yrs Hands, Feet Arms, Legs Imbalance Diabetic Neuropathy

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Stanley Jones P. Iyadurai, MSc, PhD, MDAssistant Professor of Neurology

Neuromuscular Division, Department of NeurologyThe Ohio State University Wexner Medical Center

“Doc, DO I Have Neuropathy?” Case VignettesCase Vignettes

Susan, 50

DM – 12 yrs

B/N/T – 2 yrs

Hands, Feet

Arms,Legs

Imbalance

Gwenn, 32

Hypothyroidism

N/T at night 3 months

Right hand

DifficultyOpening jars

Normal gait

John, 52

No PMH

B/N/T – 6 days

Hands, ArmsFeet, Legs

PainBreathing

Imbalance

Sally, 42

No PMH

B/N/T – few months

Hands, FeetBurning Pain

PainRedness

Normal Strength

“Neuropathy” - Definition“Neuropathy” - Definition

• “Neuron” and “Pathos” (Greek)

• Disease of the Peripheral Nerve

• Dysfunction of the nerves outside of the central nervous system

Neuropathy - General ThemeNeuropathy - General Theme

• Symmetric

• Insidious

• More prominent distally and starts in legs

• Involves both motor and sensory components

• May cause pain

• May cause loss of balance

• Progressive, but not debilitating

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Not all that tingles is neuropathy

Not all that tingles is neuropathy

‘numbness and tingling’

• not all numbness and tingling is peripheral nerve

• RLS

• edema

• deconditioning

• central nervous system

• nerve root [‘sciatica’]

Classification - FunctionalClassification - Functional

• Motor – affects the motor nerves Weakness• Sensory

‒ Pain‒ Small Fiber‒ Large Fiber‒ Large and Small Fiber‒ Neuronopathy (ganglionopathy)

• Autonomic• Sweating Changes, Blood Pressure Changes

Classification – Time-courseClassification – Time-course

• Acute

Immune-mediated

• Infantile Weakness

• Childhood-onset

• Relapsing

• Hereditary

· Motor-Sensory

· Motor Syndromes

· Sensory Syndromes

Classification – Time-courseClassification – Time-course

• Congenital/Hereditary

• Acquired‒ Reversible?‒ Demyelinating?‒ Immune-mediated?‒ Systemic diseases?

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Neuropathy - EvaluationNeuropathy - Evaluation

• Detailed History

• Family History

• Clinical Examination

• Blood Work

• Special Tests – EMG/NCS

• Special Tests – Imaging

• Special Tests – Nerve/Muscle/Skin Biopsy

ExaminationExamination• Vibration sense – the most sensitive test• Quantitative Tuning Fork (Rydel-Seiffer)• Pin scratch test (gradient)• Proprioception• Temperature sense – comparisons• Reflexes• Distal strength testing‒ “Bring your toes up” ‒ “Curl your toes down”‒ “Spread your toes”

Amro Stino, MDAssistant Professor-Clinical

Division of NeurologyThe Ohio State University Wexner Medical Center

“Doc, DO I Have Neuropathy?”Work-upWork-up

• CBC, CMP, LFTs• ESR, CRP, RF, ANA, ENA, ANCAs, ACE• Hgb A1c, fasting glucose, 2h glucose tolerance,

TSH, T3, T4, B12, MMA, B6, B1, D• Lyme titer, RPR, HIV, Hepatitis panel,• Quantitative immunoglobulins, Special

antibodies• immunofixation electrophoresis• CSF• EMG/NCS, consider MRI Brain/Spine, CT-C,A,P• Nerve/muscle biopsy, Skin biopsy*, Autonomic

testing*

*consider if EMG/NCS normal

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‘The Big 4’ – The Most Common

‘The Big 4’ – The Most Common

• Diabetes AND impaired glucose tolerance

‒ A1c, 2h glucose tolerance test, fasting glucose

• B12 deficiency

‒ B12 + MMA

• Alcohol

‒ CAGE questionnaire

• Plasma cell dyscrasias (paraproteinemias) –

‒ immunofixation electrophoresis

Nerve Conduction Studies (NCS)

Nerve Conduction Studies (NCS)

Electromyography (EMG)Electromyography (EMG) Autonomic testing – sweat output as measure of small fiber

neuropathy = QSART

Autonomic testing – sweat output as measure of small fiber

neuropathy = QSARTLENGTH DEPENDENT SWEAT LOSS – DISTAL IS < 1/3 PROXIMAL SWEAT VOLUME

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Autonomic Testing -Loss of Heart Rate Variation to Deep Breathing =Cardiac wall remodeling in diabetics = Poor Prognosis

Autonomic Testing -Loss of Heart Rate Variation to Deep Breathing =Cardiac wall remodeling in diabetics = Poor Prognosis

Courtesy of Brent Goodman, MD

Autonomic Testing -Loss of Heart Rate Variation to Deep Breathing =Cardiac wall remodeling in diabetics = Poor Prognosis

Autonomic Testing -Loss of Heart Rate Variation to Deep Breathing =Cardiac wall remodeling in diabetics = Poor Prognosis

Virtually no heart rate variation

Courtesy of Brent Goodman, MD

Stanley Jones P. Iyadurai, MSc, PhD, MDAssistant Professor of Neurology

Neuromuscular Division, Department of NeurologyThe Ohio State University Wexner Medical Center

“Doc, DO I Have Neuropathy?” Why Do We Care About Details?

Why Do We Care About Details?

• Not to Miss a Treatable Cause

• Not to Miss an Immune-mediated Neuropathy – since it is often treatable

• Prevent Further Worsening of Neuropathy

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CausesCauses• Metabolic

• Vitamin deficiencies

• Inflammatory conditions

• Infections

• Cancer

• Drugs, Toxins

• Nerve injury at specific locations

• Immune Mediated Neuropathies

• Genetic

MetabolicMetabolic

• Diabetes

• Thyroid

• Uremic (usually on hemodialysis)

Vitamin DeficienciesVitamin Deficiencies

• Vitamin B12

• Vitamin B6

• Vitamin B1

• Vitamin E

Inflammatory conditionsInflammatory conditions

• Vasculitides – often are very painful, multifocal, and require nerve and muscle biopsy. Treated with steroids and immunosuppressants

EVALUATE FOR SECONDARY CAUSES• Systemic Lupus Erythematosus

• Celiac Sprue-related Neuropathy

• Connective Tissue Disorders

• Sarcoidosis

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InfectionsInfections

• HIV

• Hepatitis

• Lyme disease

• Leprosy

CancerCancer• Due to any cancer in general

• Lymphoma

• Multiple Myeloma

• Result of Cancer Treatments

• Paraneoplastic – Specifically anti-Hu

ParaproteinemiasParaproteinemias• MGUS – often mimics CIDP

(demyelinating)

• Waldenstrom – more axonal

• Amyloidosis – get significant autonomic disturbance

• Multiple Myeloma – neuropathy usually results more from chemotherapy (bortezomib)

• POEMS – Polyneuropathy, Organomegaly, Endocrinopathy, M-protein Spike, Skin Changes.

Drugs, ToxinsDrugs, Toxins• Chemotherapy drugs• Amiodarone• Dilantin• Disulfiram• Dapsone, Ethambutol• Leflunomide• Alcohol• “Huffing”• Agent Orange

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Nerve InjuriesNerve Injuries

• Carpal Tunnel

• Ulnar Neuropathy

• Common Peroneal Neuropathy

Immune-Mediated Neuropathies

Immune-Mediated Neuropathies

• Evaluation based on specific antibodies in the

serum

• Common ones: anti-GM-1, anti-GQ1b, anti-

tubulin and anti-Hu, anti-TS-HDS

• Treatment is related to immune therapies and

immunomodulation

• IVIG, Plasmapheresis, Steroids, Rituximab

Amro Stino, MDAssistant Professor-Clinical

Division of NeurologyThe Ohio State University Wexner Medical Center

“Doc, DO I Have Neuropathy?”Autoimmune Neuropathy

SpectrumAutoimmune Neuropathy

Spectrum

• Acquired, Immune Mediated Neuropathies

‒ GBS – reaches nadir in < 4 weeks

‒ CIDP – reaches nadir in > 8 weeks

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Acquired Demyelinating Features

Acquired Demyelinating Features

Pictures from neuromuscular.wustl.edu, courtesy of Dr. Alan Pestronk

Typical GBS (AIDP)Typical GBS (AIDP)• 90% + of GBS have AIDP presentation• Sensory phase of 3 - 10 days

‒ Numbness, tingling, tightness‒ Pain in 75-90%: often in the lower back or proximal legs

• Weakness spreads from legs to arms‒ Facial involvement in about 50% of otherwise typical

cases‒ DTRs decreased to absent –

• not always global• Autonomic involvement in ~ 70% (may be severe)

‒ Requires ICU stay• 25-40% require ventilator assistance (may be very rapid)

‒ 1/3 require intubation‒ Predictors of impending respiratory failure may prompt

PLEX instead of IVIG to allow for faster treatment response

GBS Diagnostic CriteriaGBS Diagnostic Criteria

Necessary Criteria Supportive Criteria

Symmetric weakness Sensory sx./signs

Areflexia CN weakness (VII)

Progression < 4 weeks ANS dysfunction

High CSF protein

Demyelinating EPS

GBS OverviewGBS OverviewTypical• Acute Inflammatory Demyelinating

Polyradiculoneuropathy (AIDP)Atypical• Acute Motor Axonal Neuropathy (AMAN)• Acute Motor Sensory Axonal Neuropathy

(AMSAN)Both AMAN and AMSAN have association with GD1aand GM1 • Miller Fisher Variant (MFS) – GQ1b• Pharyngeal Cervical Variant – GT1a

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GBS TreatmentGBS Treatment

• Responds to IVIG or Plasmapheresis

Chronic Inflammatory Demyelinating

Polyradiculoneuropathy

Chronic Inflammatory Demyelinating

Polyradiculoneuropathy

• Chronic progressive, stepwise, or recurrent symmetric proximal and distal weakness and sensory dysfunction of all extremities, developing over at least 2 months and

‒Absent or reduced reflexes in all extremities

CIDP Supportive FindingsCIDP Supportive Findings1. Elevated CSF protein with leukocyte count < 10/mm

(level A)

2. MRI showing GAD enhancement and/or hypertrophy of cauda, lumbosacral, or cervical nerve roots, or brachial or lumbosacral plexus (level C)

3. Abnormal sensory electrophysiology in at least one nerve (good practice point)

1. Normal sural with abnormal median (excluding CTS) or radial SNAP

2. CV < 80% of LLN (<70% if SNAP amplitude <80% of LLN)

3. Delayed SSEPs without CNS disease

CIDP TreatmentCIDP Treatment

• Responds to IVIG, Steroids, or Plasmapheresis

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Multifocal Motor NeuropathyMultifocal Motor Neuropathy

• Associated with anti-GM1 IgM antibodies• Antibodies bind to node of Ranvier structures of

motor axons (GM1 enriched) and fix complement.• Incidence: 0.6/100K• Clinically:

‒ non-contiguous motor nerves affected‒ weakness far in excess of atrophy noted (in

distinction to MND)‒ asymmetric upper limb onset without sensory

complaints‒ 20-30% can have brisk tendon reflexes‒ Combining galatocerbroside with GM1

increases sensitivity to 75%

Neuropathy – Treatment Principles

Neuropathy – Treatment Principles

• Address Reversible Causes of Neuropathy‒ B12 deficiency - 2000mcg daily by mouth or IM‒ B6 toxicity – reduce amount‒ Alcohol abuse – abstinence, vitamin

replenishment• Pain Management – Try different classes +/-

Tramadol before going to Opiates‒ Tricyclics‒ SNRIs‒ Sodium Channel Blockers‒ Calcium Channel Blockers‒ Tramadol‒ Opiates (long-acting)

TreatmentTreatment

• Anticonvulsants‒ Gabapentin‒ Pregabalin‒ Topiramate‒ Lamotrigine‒ Carbamazepine‒ Oxcarbazepine

TreatmentTreatment

• Antidepressants

‒ Amitriptyline (TCA)

‒ Nortriptyline (TCA)

‒ Desipramine (TCA)

‒ Duloxetine (SNRI)

‒ SSRIs

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TreatmentTreatment

• Topical Anesthetics

‒ 5% Lidocaine patch

‒ 0.075% Capsaicin patch

• Opioids

‒ Tramadol

‒ Oxycodone

Common MimicsCommon Mimics

• RLS

‒ Requip

‒ Check Ferritin

• PLMS

‒ Sleep study

Stanley Jones P. Iyadurai, MSc, PhD, MDAssistant Professor of Neurology

Neuromuscular Division, Department of NeurologyThe Ohio State University Wexner Medical Center

“Doc, DO I Have Neuropathy?”Case PresentationCase Presentation

• 54-year old man presents to the ER with recent onset of numbness and tingling in bilateral hands and feet (“stocking-glove distribution”)

• Examination – Reportedly Normal

• Blood sugar – 127 (Elevated)

• Diagnosis?

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Case presentation (Cont’d)

Case presentation (Cont’d)

• Diagnosis: “Diabetic neuropathy”

‒ Start metformin

• 2 days later, “increased numbness, worse tingling, and with pain”

• Examination with diminished reflexes

‒ Diagnosis: ?

Case Follow-upCase Follow-up

• CSF: Protein elevated at 124

• Diagnosis: Guillain-Barre Syndrome‒ IVIg treatment with full remission

Genetic causesGenetic causes• Suggested by a very long course

• No treatable reason found despite repetitive evaluation

• Loss of strength (motor nerves damaged) without much reported sensory loss (usually)

• Pain < dysfunction

• Family history

Genetic causesGenetic causes• Charcot-Marie-Tooth disease

‒ Many forms, many genes

• HNPP (PMP-22)

‒ “Tool-belt” pressure causing pain and weakness

‒ “Foot drop”

• Porphyria

• Amyloidosis

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Rare genetic causesRare genetic causes

• Fabry’s disease (alpha-galactosidase)

• Metachromatic leukodystrophy (aryl sulfatase)

• Adrenoleukodystrophy

• Refsum’s disease (phytanic acid)

Hereditary NeuropathiesHereditary Neuropathies

Neuropathic GaitNeuropathic Gait Hereditary NeuropathiesHereditary Neuropathies

Chronic sensory neuropathyHigh arches & Hammer toes

Preserved gastrocnemius size

CMT 1APMP-22

duplicationCMT 1X CMT 2A2

Pictures from neuromuscular.wustl.edu, courtesy of Dr. Alan Pestronk

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Case VignettesCase VignettesSusan, 50

DM – 12 yrs

B/N/T – 2 yrs

Hands, Feet

Arms,Legs

Imbalance

Gwenn, 32

Hypothyroidism

N/T at night 3 months

Right hand

DifficultyOpening jars

Normal gait

John, 52

No PMH

B/N/T – 6 days

Hands, ArmsFeet, Legs

PainBreathing

Imbalance

Sally, 42

No PMH

B/N/T – few months

Hands, FeetBurning Pain

PainRedness

Normal Strength

Case VignettesCase VignettesSusan, 50

DM – 12 yrs

B/N/T – 2 yrs

Hands, Feet

Arms,Legs

Imbalance

Diabetic Neuropathy

Gwenn, 32

Hypothyroidism

N/T at night 3 months

Right hand

DifficultyOpening jars

Normal gait

John, 52

No PMH

B/N/T – 6 days

Hands, ArmsFeet, Legs

PainBreathing

Imbalance

Sally, 42

No PMH

B/N/T – few months

Hands, FeetBurning Pain

PainRedness

Normal Strength

Case VignettesCase VignettesSusan, 50

DM – 12 yrs

B/N/T – 2 yrs

Hands, Feet

Arms,Legs

Imbalance

Diabetic Neuropathy

Gwenn, 32

Hypothyroidism

N/T at night 3 months

Right hand

DifficultyOpening jars

Normal gait

Carpal TunnelSyndrome

John, 52

No PMH

B/N/T – 6 days

Hands, ArmsFeet, Legs

PainBreathing

Imbalance

Sally, 42

No PMH

B/N/T – few months

Hands, FeetBurning Pain

PainRedness

Normal Strength

Case VignettesCase VignettesSusan, 50

DM – 12 yrs

B/N/T – 2 yrs

Hands, Feet

Arms,Legs

Imbalance

Diabetic Neuropathy

Gwenn, 32

Hypothyroidism

N/T at night 3 months

Right hand

DifficultyOpening jars

Normal gait

Carpal TunnelSyndrome

John, 52

No PMH

B/N/T – 6 days

Hands, ArmsFeet, Legs

PainBreathing

Imbalance

Guillain-BarreSyndrome

Sally, 42

No PMH

B/N/T – few months

Hands, FeetBurning Pain

PainRedness

Normal Strength

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Case VignettesCase VignettesSusan, 50

DM – 12 yrs

B/N/T – 2 yrs

Hands, Feet

Arms,Legs

Imbalance

Diabetic Neuropathy

Gwenn, 32

Hypothyroidism

N/T at night 3 months

Right hand

DifficultyOpening jars

Normal gait

Carpal TunnelSyndrome

John, 52

No PMH

B/N/T – 6 days

Hands, ArmsFeet, Legs

PainBreathing

Imbalance

Guillain-BarreSyndrome

Sally, 42

No PMH

B/N/T – few months

Hands, FeetBurning Pain

PainRedness

Normal Strength

Small FiberNeuropathy